Managing Acute Confusion in The Elderly

Dr Rachel NockelsOPALS Consultant

Why is this relevant?

GP curriculum statement 9 (care of older people) requires GPs to be able to manage the problems of older people, such as confusion, in the elderly

Causes of Acute confusion

1. Delirium2. Worsening dementia3. Depression4. Alcohol withdrawal or substance

misuse5. Psychotic disorder6. Thyroid disease7. Mania8. (Schizophrenia)

NICE delerium guideline

Delirium - definition

A common clinical syndrome characterised by disturbed consciousness, cognitive function or perception which has an acute onset and fluctuating course

Definition DSM IV

disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.

a change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia.

the disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.

there is evidence from the history, physical examination, and laboratory findings that: (1) the disturbance is caused by the direct physiological consequences of a general medical condition, (2) the symptoms in criteria (a) and (b) developed during substance intoxication, or during or shortly after, a withdrawal syndrome, or (3) the delirium has more than one aetiology”.

Confusion Assessment Method

1. Acute onset and fluctuating course2. Inattention3. Disorganised thinking4. Altered level of consciousness

A positive CAM requires presence of 1 AND 2 plus either 3 or 4

European Delirium Association

DELIRIUM DEMENTIA DEPRESSION

Onset Sudden (hours to days)

Usually gradual (over months)

Gradual (over weeks to months)

Alertness Fluctuates - Sleepy or agitated

Generally normal Generally normal

Attention Fluctuates – difficulty concentrating,

easily distractible

Generally normal May have difficulty concentrating,

easily distractible

Sleep Change in sleeping pattern (often more confused at night)

Can be disturbed –night time

wandering and confusion possible

Early morning wakening

Thinking Disorganised - jumping from one idea to

another

Problems with thinking and

memory, may have problems finding

right word

Slower, preoccupied with negative thoughts of

hopelessness, helplessness or self

depreciation

Perception Illusions, delusions and hallucinations common.

Generally normal Generally normal

Theories of delirium pathophysiology

1. Cholinergic deficiency2. Aberrant stress response/

neuroinflammation

Delirium – sub types

Hyperactive Hypoactive Mixed (Subsyndromal)

Prevalence

Medical wards – 20-30% Post surgery – 10-50% Long term care – just under 20% Community- ? Up to 1%

Who Is At Risk?

Those aged 65 years and older Hip fracture Cognitive impairment Severe illness Sensory impairment Previous episode of delirium

Precipitating factors

Drugs Infection Neurological Cardiological Respiratory Electrolyte imbalance Endocrine and metabolic Constipation Change in environment

Think Pinch Me

Pain INfection Constipation Hydration Medication Environment

Consequences

Dementia/Cognitive impairment Progression of dementia Discharge to care home (for people who

were in hospital) Falls Hospital admission (for people who were

in long-term care) Post discharge care

Consequences cont.

Post traumatic stress disorder Pressure Ulcers Mortality Impact on carers Length of stay Quality of life for patients

Management

Best management is prevention

Reorientate Nurse in familiar surroundings Stop all unnecessary medications Keep lighting appropriate Put in hearing aids and wear glasses Keep well hydrated Monitor nutrition Re-align sleep wake cycle

Treatment

Identify cause(s) Ensure effective communication Use verbal and non verbal

techniques Keep moves to a minimum If a risk to themselves or others

consider short term haloperidol or olanzapine

Continue to re evaluate

De Escalation Techniques

Approach in a calm manner Give choices and maintain patient dignity Speak in a low even tone Do not maintain eye contact Do not interrupt or argue Allow space, do not touch patient Empathise with their feelings Don’t put yourself at risk

Sedation

Should be avoided If necessary use low dose and

gradually increase

Who Needs Admitting?

Live alone Will be left unsupervised for any duration

of time If carers (or RH) are unprepared or unable

to continue looking after the patient If the cause does not become clear

despite investigation or the patient fails to improve with treatment and/or

If the history and/or examination indicate a cause requiring acute hospital treatment

Conclusion

Acute confusion in the elderly is a common problem

Delirium is often missed especially hypoactive form

It can take months to resolve The consequences can be

devastating Try not to use sedation if at all

possible

Thank you

Any questions?